* Refund Period must match dates on the form # 96-0466,
Motor Vehicle/Aviation Fuel Refund Application
** UN11=Motor vehicle fuel for off highway use
Mail Drop 521M
Fuel Tax Refund Compliance Unit
Arizona Department of Transportation
PO Box 2100
Phoenix AZ 85001-2100
96-0466A R07/10 www.azdot.gov 602-712-8727
Refund Period Beginning Date* Refund Period Ending Date* Refund Account Number
G—
Page Number
of
Applicant Name Doing Business As (DBA)
Attach a copy of the invoice or purchase receipt for each fuel delivery. The invoices should be in the same order as the table below.
Purchase Date
VIN/Equipment Number
UN11** Gallons
Purchased
Beginning
Odometer
Ending
Odometer
Mileage
Off Highway
MPG
Gallons Consumed
Off Highway
Total Gallons Claimed (this page)
Total Gallons Claimed (all pages)
• Round to whole gallons.
• Transfer total to UN11 on Motor Vehicle/Aviation Fuel Refund Application.
MOTOR VEHICLE FUEL LOG
SUMMARY SCHEDULE
UN11
